Download Infectious disease, social determinants and the need

COMMENTARY
Infectious disease, social determinants
and the need for intersectoral action
Butler-Jones D1 *, Wong T1
Affiliation
Abstract
First Nations and Inuit Health
Branch, Health Canada, Ottawa,
ON
1
Effectively addressing infectious diseases requires a broad multifaceted approach. Public
health efforts in the 19th century emphaasized cleanliness and good living conditions. The germ
theory of disease that subsequently prevailed led to some important breakthroughs in vaccines
and antimicrobials—but also bred complacency. Now, in light of emerging and re-emerging
infections and antimicrobial resistance, we know that a unidisciplinary approach to infectious
disease control is no longer sufficient and that it is through working with others that we can
identify practical ways to address all the factors at play in the emergence and persistence of
infectious diseases. When working across sectors, inter-professionally or with intergovernmental
or coalition activities, there are four important principles to apply: respect, practicality, the rule
of three and having something to offer.
*Correspondence: [email protected]
Suggested citation: Butler-Jones D, Wong T. Infectious disease, social determinants and the need for
intersectoral action. Can Comm Dis Rep 2016;42-Suppl 1:S18-20.
Introduction
Tackling the challenge of infectious disease has always required a
broad multifaceted approach. As our understanding has evolved,
this approach has expanded to include the concept of social
determinants of health (SDOH) to better address the complex
interplay between the conditions in which we live and our ability
to foster health and recover from illness (1). This paper describes
the history of our understanding of infectious diseases, from
germ theory to the determinants of health and beyond, identifies
the need for an intersectoral approach and relates principles that
foster coalition building and effective intersectoral action.
Germ theory
The germ theory of disease led to some important
breakthroughs that helped in the eradication of some
diseases and the near elimination of others through the use of
vaccines and antimicrobials. Nevertheless, the theory was very
controversial and much debated in the 19th century. There were,
for example, those who feared that if we concluded germs
were the actual cause of disease, people would no longer be
motivated to clean up the dirty conditions in which infections
often arose (2).
The mid-20th century was marked by the hubris that infection
was no longer a serious threat to humanity (3). As germ theory
became widely embraced, the tendency to become a little more
complacent with the surrounding conditions became an issue.
For example, during surgery, people assumed that antibiotics
could address any risk of postoperative infection and became a
little more lax with aseptic technique. Overall, less attention was
paid to infection control and public health efforts.
Complacency regarding infectious diseases is now largely absent.
This change began in the 1980s and 1990s with the onset of the
HIV epidemic and continued through the 2000s, with the SARS
and pandemic H1N1. The emergence of antimicrobial resistance
(e.g. multidrug-resistant tuberculosis), new infectious diseases
(e.g. the Ebola virus) and the re-emergence of old infectious
diseases thought to be vanquished (e.g. pertussis) have also
challenged complacency.
The more we know about infection, the more we realize we have
to learn. Prions and related protein misfolding disorders point to
a type of infectious disease not caused by a
microorganism—and this will likely not be the last form of
infectious organism we discover (4). And with each year, new
insights increase our understanding of how microorganisms
cause or promote a growing range of diseases and immune
disorders.
The interplay of microbes and social
determinants
We have come to recognize, or perhaps rediscover, the
significant influence of social determinants on rates of infectious
and noninfectious disease and mortality. Where we live and how
we behave—our social, environmental and economic
context—all bear on our well-being and survival.
So, in a way, we have come full circle. We realize that the germ
theory of disease was a little too simple, and now have a more
nuanced understanding of the role microorganisms play in a
range of diseases, their function in promoting normal
physiological processes, such as digestion, and their complex
interplay with immunity (5). But we also realize that there was
a lot of substance in the early public health movement, with its
focus on better sanitation and generally improving economic and
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COMMENTARY
social conditions. While, overall, social and economic conditions
for health have significantly improved over the last century,
especially in developed countries, neglecting to address social
determinants has given rise to inequity (6,7). To successfully
prevent and manage disease and injury, we must take into
account all we know about microorganisms, vaccines, treatments
and SDOH. With that in mind, the concept of One Health
is gaining acceptance as another way of thinking about the
problems we face. The interface of animal, human, environment
and economic factors is where many solutions to our more
complex challenges lie.
A fascinating example of the interplay of SDOH and microbes
is the fact that the incidence of TB started to decline in much
of Western society prior to the advent of successful medical
therapies (8). Better housing, less overcrowding, improved
nutrition and living conditions, and pasteurization, among other
factors, contributed to a precipitous decline in rates of TB in the
19th and early 20th century in Europe and North America (9).
Ironically, although a number of effective treatments for TB
were developed in the latter half of the 20thcentury, the disease
has not been eliminated. This is due to a complex combination
of SDOH, immunological factors (such as the increase in TB in
those with HIV), and the emergence of multidrugresistant strains
of the bacteria (10). TB remains endemic in many countries
including in the Americas, among indigenous populations. One
key to a longer-term solution to TB in Canada’s North is access
to adequate housing in addition to prevention and treatment
(11-13).
TB is not the only example of an important interplay between
microbes and SDOH. The burden of methicillin-resistant
Staphylococcus aureus (MRSA) and respiratory syncytial virus
(RSV) is associated with inadequate housing and poverty (14,15).
Even the burden of HIV/AIDS—who gets it and how well they
respond to treatment—is related to SDOH. For example, people
with HIV who have stable housing are more likely to have better
treatment adherence (16).
Effectively addressing infectious disease means no longer
debating whether to focus on social or on medical, biological
or environmental factors (17,18); all these factors are
important. This also suggests that no one person or group
can address all infectious diseases. In fact, to effectively
address infectious diseases today requires multiple skill sets—
knowledge of infectious disease, public health and SDOH and
the ability to work with local communities, governments and
non-governmental organizations.
Why we need coalitions and
intersectoral action
housing and social conditions, the health care system offered
immunization and, as a result, brought down the rates of the
disease in those communities to below that of the province as a
whole. (Unpublished Saskatchewan Communicable Disease data
1994–99, Dr. Shauna Hudson).
One of the challenges of addressing SDOH is that they are
not simply deterministic. In other words, just because a person
is financially better or worse off is not in itself a reason for
good or ill health. Poverty is not just an economic issue; it is a
constellation of lack of assets, connections, self-determination,
environment, etc. Some communities thrive much better than
others with similar levels of income, environment, genetics
and basic culture. And these can be mitigated further with
appropriate supports in education, health and social services.
With such diversity in the human condition and approaches
to dealing with issues, one of our key challenges is helping
communities journey from where they are to what they could be.
Sometimes the issues of poverty, social, environmental and
economic factors and our ability to influence them seem
overwhelming. While no one can do it all, and some challenges
seem insurmountable, breaking the problems down in practical
ways can be helpful in assuring positive action.
Principles for working with multiple sectors
and coalitions
No one ideal technique or model is suited to all people or
situations. The key is improving our understanding of the various
factors underlying risks and benefits to health through working
with others so that we can identify practical ways to address all
the factors that may be at play.
The skills required to address infectious diseases in the context
of social determinants may take us beyond our usual roles.
Diplomacy, coalition building, community development are just
some of the key capacities that allow us to address the risks and
underlying factors. Four important principles apply.
Respect
We cannot influence who or what we do not respect. While
it is not necessary to look on those we work with to achieve
shared goals as friends—or even to agree with them—we need
to respect them as people and appreciatethe challenges they
face and their aspirations. Only then can the conversation about
potential change take place. When we feel frustrated over
differences, a harangue may feel therapeutic but these rarely
lead to a significant change in perspective; the most common
reaction is wanting as little as possible to do with the haranguer.
So working in a spirit of respect is critical.
Make it practical
Unidisciplinary disease control strategies will never be truly
sufficient to combat many infectious diseases: the underlying
determinants of health also need to be addressed. If we keep in
mind the importance of SDOH and other non-microbial factors
when organizing health services, we are more likely to come up
with effective strategies.
It is not enough to identify the problems. Policymakers
and others also need practical, doable solutions that are
demonstrable and/or feasible. Applying what we already know
or can gather from experience elsewhere and understanding
effective implementation can mean going a long way without the
need for new strategies and technology.
An example of the effective multidisciplinary application of
infectious disease control is the use of a vaccine to stop the
periodic outbreaks of hepatitis A in small remote communities
in Saskatchewan. While advocating for improvements in
The rule of three
Page S1-19
Too often the things people disagree about become the focus
of meetings and hinder progress. To address this, stop, take
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COMMENTARY
stock and divide the issues up into three areas: those that can
be agreed on, those that are not perfect but can be lived with,
and those that are very unlikely to be agreed on. While not
completely ignoring the last category, focussing most of the
effort on the others prevents just the one category consuming
more than a small part of the available time and energy.
Have something to offer
It is rare that one single organization has either the mandate or
capacity to address large complex issues alone. The reason for
coalitions is that different groups have different things to offer, so
identifying what you or your organization can offer is very useful.
A conversation that goes along the lines of “We could do this if
you could do that” has been a useful technique for breaking the
logjam of problems circling between organizations.
Conclusion
Enhancing our biomedical approach to address infectious
diseases with effective approaches based on the SDOH and
One Health will be a key to long-term success. Whether in
medicine or policy, the basics matter. Ensuring the least intrusive,
most effective approaches with the fewest side effects serves us
all well.
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Acknowledgements
We wish to thank everyone working in coalitions and
intersectoral action to improve the health for all.
Conflict of interest
None.
13. Kulmann KC, Richmond CA. Addressing the persistence of
tuberculosis among the Canadian Inuit population: The need
for a social determinants of health framework. Int Indigen
Policy J. 2011;2(1):1-16.
14. Tong SY, McDonald MI, Holt DC, Currie BJ. M. Global
implications of the emergence of community-associated
methicillin-resistant Staphylococcus aureus in Indigenous
populations. Clin Infect Dis. 2008;46:1871-8.
15. Colosa AD, Masaquel A, Hall CB, Barrett AM, Mahadevia
PJ, Yogev R. Residential crowding and severe respiratory
syncitial virus disease among infants and young children: A
systematic literature review. BMC Infect Dis. 2012;12 (95.
doi:10.1186/171-2334-12-95).
Funding
None.
16. Rourke SB, Bacon J, McGee F, Gilbert M. Tackling the social
and structural drivers of HIV in Canada. Can Commun Dis
Rep. 2015;41(12). http://www.phac-aspc.gc.ca/publicat/ccdrrmtc/15vol41/dr-rm41-12/ar-03-eng.php
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